[G-BLEW]

The accident report has now been published, and a couple of threads Navigation Apps & CFIT and "I can't die because I've got an instructor sitting next to me" refer to certain elements, but I hope this 'post AAIB report' thread might be able to draw some additional learning points from this tragedy.

Since reading it a coupe of times I've been asking myself these questions

- Would I have departed?
- Assuming I had departed, what would make me turn back/divert? I've done that a few times over the years, but I don't (think) I have a consistent way of making that decision.
- How reliable (generally) are the warnings of ice in F215
- Would I have climbed to a safe altitude?

One thing I do know, had I departed on that day, I would not have done it without having a phone/tablet/moving map GPS of some kind.

What can we learn, and what would you have done (and why)?

Ian

[PeteSpencer]

Three threads now covering the same tragic accident.
Some contain startling accusations/allegations.
I do hope the families of the deceased don't have access to flyer forum.
I have my own private thoughts about this accident but will keep them to myself,principally because others will (claim to) be more knowledgeable than me and I'm through with opinionated threads.

Peter

[alexbrett2]

A question I've been asking myself is if I were in the position the instructor found himself in during the flight, (I'm making an assumption that the low level orbits recorded were due to becoming uncertain of position or similar), and for whatever reason I didn't have a moving map or similar available, would I have contacted a radar service / D&D for assistance?

I would hope I would, but the couple of times I've had 'problems' (e.g. an alternator failure at night), I've been reticent to declare a pan or similar at the time. In an instructional situation this could be even worse as you have the added (or at least perceived) pressure of perhaps not wanting to worry the student.

[G-BLEW]

Three threads now covering the same tragic accident.
Some contain startling accusations/allegations.

This thread is about learning from the tragedy.

I do hope the families of the deceased don't have access to flyer forum.

I know what you mean, but again this thread is about learning from the tragedy. The instructor/examiner and student are no longer with us, learning is about reducing the chances of it happening to one of us in the future.

I have my own private thoughts about this accident but will keep them to myself,principally because others will (claim to) be more knowledgeable than me and I'm through with opinionated threads.

How did it work in medicine?

Ian
PS Others will be more knowledgeable than you and me, but that's a good thing right?

[Balliol]

A couple of observations:

The report talks about GPS moving map apps as if GPS wasn't used. I think the point is that the aircraft had a Garmin 430, but how useful is that for terrain avoidance?

I suspect the orbits were a hold trying to ascertain whether weather was fit to continue / considering divert as opposed to being lost.

I find it odd why the report fails to produce the METARs and TAFs which would have been available from Gloucester, why it only focuses on the 215 which is a wide area, generalised forecast I don't know.

In that situation I would like to think I would have climbed and taken my chances with the icing. However, the human factor urge to stay 'visual' is very strong.

Both aircraft were on Gloucester freq with the other one ahead, WAVS probably heard the other one getting there 'ok' so another human factor urge to continue.

[Bathman]

Do we know what the tempreture was?

[gasman]

METAR EGBJ 081250Z 05003KT 3500 -DZ BR BKN006 OVC010 02/02
Q1021=

[Cessna57]

Discussed that report with my wife this morning, who doesn’t fly (not even as a passenger).

She has no concept of pressonitis or gethomeitis or gettothecamoitis or human factors and so it led to an interesting discussion.

One thing that stands out is that it’s definitely human factors, chance to not take off, chance to turn round, chance to talk to D&D.

I’ve been accused of going to “Defcon 1” too easily in the past. I.E. talking to D&D, declaring a pan, or turning back, while I continue to read reports like this, I’ll continue to go to defcon1 earlier rather than later. (I don’t even think that’s defcon1, defcon1 is declaring a MayDay and landing at Heathrow, and I’m prepared to give up my license and do that if I think I ever need to)

One day I’ll be “experienced” and what worries me is that one day I’ll think, “this is iffy, but that’s ok, I’ve got this” and I won’t have it.

To my mind that’s what’s happened, and you can’t blame anyone for being human, and you can’t be a “better human”, so I’ll have to try and always continue to be an overly cautious human, because when I’m experienced “overly cautious” will still be a lot less cautious than a student. (for instance)

[Rob P]

05003KT 3500 -DZ BR BKN006 OVC010

[johnm]

An experienced pilot with instrument qualifications is faced with a marginal decision. The critical issue is the layer below zero between 1000 4000 then freezing level at 5000 to 7000. That offers some limited options to stay out of icing conditions. Usually ST or SC only implies light icing but there was a forecast of severe icing in isolated areas unspecified.

[Chris Martyr]

Was there any peer pressure for these guys to depart in the first place ?

This has all the unfortunate characteristics of the sort of thing you encounter on H/F courses.

When did the holes in the swiss cheese start to line up .

[Awful Charlie]

Reading the AAIB report reminded me of Vasa Babic's excellent "IFR Safety review" (available from https://www.pplir.org/component/joomdoc ... pdf/detail ) which although initially may not seem very relevant, from the SOP section from page 58 onwards does seem to have a significant overlap.

[TLRippon]

When enquiring about IR training with a flying school, I asked if there would be a higher rate of cancellation in the winter due to weather. I was told, "No we don't cancel, we are teaching IR".
I think this may have reinforced my decision to seek training elsewhere.

[johnm]

The puzzling aspect of this is why they were orbiting near Evesham. They were on a direct track to join down wind for 04 consistent with the METAR. Had they simply carried on that's where they'd have ended up, which is what the other aircraft appears to have done. The had OBS on the GARMIN box which would have orientated them too.

[Flyin'Dutch']

I’ve been accused of going to “Defcon 1” too easily in the past. I.E. talking to D&D, declaring a pan, or turning back, while I continue to read reports like this, I’ll continue to go to defcon1 earlier rather than later. (I don’t even think that’s defcon1, defcon1 is declaring a MayDay and landing at Heathrow, and I’m prepared to give up my license and do that if I think I ever need to)

The very right attitude to have to my mind.



The trick is to recognise when the dominoes are starting to fall or lined up in a way that them tumbling over is likely to go and happen and have a duff outcome, that together with the knowledge that you don't know everything, cannot handle everything are very good starting principles.